N.J. Admin. Code § 8:111-4.1

Current through Register Vol. 56, No. 21, November 4, 2024

Section 8:111-4.1 - Responsibility of the governing authority

(a) Every facility shall have a governing authority, which shall assume legal responsibility for the management, operation, and financial viability of the facility. The governing authority shall have written policies and protocols for the following:

1. The organization's mission and purpose;

2. Ensuring that the organization is operating in accordance with its mission and, for non-profits, the purpose for which it was granted tax-exemption;

3. Providing financial oversight to ensure that proper financial controls are in place;

4. Ensuring adequate financial resources as part of their fiduciary responsibility, which may include such responsibilities as personal contribution, financial planning, fundraising, grants management and serving as an advocate;

5. Exercising duty of care (reasonable care while decision making), duty of loyalty (acting in the best interests of the organization without personal gain) and the duty of obedience (being faithful to the organization's mission while managing funds for that purpose);

6. Appointing and supervising an administrator (that is, president, CEO, executive director, etc.) whose references, credentials, professional license and criminal background are reviewed and verified, and reconciled with the organization's mission and administrator's scope of work.

i. The governing authority shall establish policies for hiring an administrator, including policies for individuals who may have past criminal convictions and/or have been sanctioned for professional ethical violations, which ensure that convictions/violations shall not impact his or her ability to perform duties.

ii. The governing authority must advise the administrator that he or she must disclose to the governing authority any disciplinary outcome imposed as a result of an investigation by any State licensing agency, law enforcement agency or professional disciplinary review board, such as disciplinary probation, suspension of license, revocation of license or criminal conviction at the time of initial employment and/or during employment if the action occurs after hire;

7. Evaluating, at least annually, the performance of the administrator of the facility, including establishing requirements for the administrator's continuing education and professional development;

8. Approving, in writing, a person to be designated as the administrator's alternate;

9. Ensuring that the administrator has the professional support needed to further the mission and goals of the organization;

10. Ensuring legal and ethical integrity and maintaining accountability by observing legal standards and ethical norms;

11. Documenting all of the governing authority's actions and those of its committees by written minutes and maintaining minutes of meetings, including resolutions and motions pertaining to the fiscal and legal responsibilities of the governing authority;

12. Establishing a grievance mechanism available to both staff and clients;

13. Establishing a written notice system accessible to all staff and clients regarding the grievance procedures that shall include the name, address and telephone number for public access to the agency;

14. Establishing a feedback mechanism in order to receive and respond to staff and client recommendations;

15. Establishing client complaint procedures that support client rights, that are conspicuously posted and accessible to clients in client service areas and are understood by clients from point of service admission to discharge, as per N.J.A.C. 8:111-6;

16. Reviewing and approving plans to establish new programs, or to substantially alter or discontinue existing services, substantial changes in levels of service and/or changes in populations served;

17. Ensuring that the client care policies required at N.J.A.C. 8:111-6are developed and maintained;

18. Establishing a pharmacy and therapeutic committee, if so required at N.J.A.C. 8:111-14.1(b);

19. Ensuring that infection control protocols and practices are adhered to;

20. Establishing protocols regarding child abuse and neglect, sexual abuse, elder abuse and institutional abuse or neglect, including duty to warn and protect;

21. Reviewing and approving the annual audits;

22. Reviewing and approving the facility's compensation plan for staff at least annually;

23. Establishing and approving an annual budget, including any capital projects, for all services to be provided at or through the facility in consultation with the administrator, fiscal officer and the service directors; and review with the administrator any material changes that may occur during the year with respect to either revenue or expenditures, including the reasons for the change;

24. Designating a member to certify financial statements by signature and establishing protocols to periodically review a sliding scale fee for services schedule, as well as procedures for assessing income and ability to pay for services;

25. Reviewing any notices issued by the Division regarding non-compliance with any requirements of this chapter or any violations of law by the facility, staff, volunteers, or consultants, ensuring corrective measures have been taken, and where appropriate, advising the Division of such corrective measures;

26. Establishing policy and procedures to ensure client's confidentiality as required by State and Federal laws (such as 42 CFR Part 2, HIPAA, etc.);

27. Developing conflict of interest and disclosure policies for members of the governing authority, paid and volunteer staff; and

28. If multiple facilities are operated by the governing authority, identifying how the committees and/or committee functions required by this chapter will be met if organization-wide committees are established.

(b) The governing authority shall act in accordance with a plan of operation or bylaws that shall set forth policies and procedures for its conduct and oversight of the operation of the residential substance use disorders treatment facility, including:

1. The composition of the governing authority, qualifications of members and officers, procedures for election or appointments to seats (including mid-term vacancies), terms of service; a written policy preventing nepotism by relatives and family members and preventing paid staff members from serving on the governing body; and a protocol to ensure that references and credentials of all prospective members are checked and verified, including written acceptance/exclusionary criteria to address individuals with past criminal convictions and/or ethical violations;

2. Establishment of standing and ad hoc committees, their duties and powers, terms of chairpersons and qualifications for chairpersons and committee members;

3. The methodology by which the governing authority shall approve bylaws, including amendments, policies and procedures required to be maintained by the facility under this chapter and documentation of such approval;

4. Establishment of schedules for review of all policies, procedures and bylaws of the facility;

5. The rules for board meetings, including the frequency and number of members necessary for a quorum;

6. The authority and responsibilities of the administrator and designee as described at N.J.A.C. 8:111-1.7, including his or her reporting responsibilities to the governing authority;

7. Establishment of the methodology by which financial books and fiscal records shall be maintained, consistent with the standards of this chapter, schedules for regular audits, both internal and independent and the basis for spot audits by independent sources;

8. Delineation of those services that shall be provided through written agreement;

9. Delineation of a grievance procedure for staff and clients; and

10. Reviewing plans of correction and deficiency reports.

N.J. Admin. Code § 8:111-4.1

Amended and recodified from 10:161A-4.1 53 N.J.R. 2208(a), effective 12/20/2021